Provider Demographics
NPI:1396128039
Name:NEELY, MARY DARLENE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DARLENE
Last Name:NEELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1332
Mailing Address - Country:US
Mailing Address - Phone:313-772-0145
Mailing Address - Fax:
Practice Address - Street 1:3756 15TH ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1332
Practice Address - Country:US
Practice Address - Phone:313-772-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI152WL0500X152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation